Most acute coronary syndromes are caused by sudden luminal thrombosis due to atherosclerotic
plaque rupture or erosion. Preventing such an event seems to be the only effective
strategy to reduce mortality and morbidity of coronary heart disease. Coronary lesions
prone to rupture have a distinct morphology compared with stable plaques, and provide
a unique opportunity for noninvasive imaging to identify vulnerable plaques before
they lead to clinical events. The submillimeter spatial resolution and excellent image
quality of modern computed tomography (CT) scanners allow coronary atherosclerotic
lesions to be detected, characterized, and quantified. Large plaque volume, low CT
attenuation, napkin-ring sign, positive remodelling, and spotty calcification are
all associated with a high risk of acute cardiovascular events in patients. Computation
fluid dynamics allow the calculation of lesion-specific endothelial shear stress and
fractional flow reserve, which add functional information to plaque assessment using
CT. The combination of morphologic and functional characteristics of coronary plaques
might enable noninvasive detection of vulnerable plaques in the future.
